Transcript Document

UIC State of the
Science Integrated
Health Conference
October 17, 2014
Implementing a Diabetes Registry and
Care Coordination in Community Mental and Physical
Health Clinics
Jessica A. Jonikas, M.A., Crystal M. Glover, Ph.D., & Judith
A. Cook,
Jonikas,
Glover, &Ph.D.
Cook, 2014
www.cmhsrp.uic.edu/health/
Today’s Presentation
Diabetes as a public health crisis
UIC Diabetes Care Coordination & Registry Study
The case for registries: benefits and evidence
Using a registry to support population management and selfmanagement
Preliminary results from our study
Considering key barriers
Reflections on next steps
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/
With thanks to our funders
 U.S. Department of
Education, National Institute
on Disability & Rehabilitation
Research
 Substance Abuse & Mental
Health Services
Administration, Center for
Mental Health Services
Cooperative Agreement
#H133G100028
Jonikas, Glover, & Cook, 2014
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Registry & Care Coordination Collaborators
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UIC Center on Psychiatric Disability & CoOccurring Medical Conditions
UIC College of Nursing, Integrated Health
Care Clinics
Thresholds Psychiatric Rehabilitation Centers
UIC Eye & Ear Infirmary & Dr. LaVallee
Kennedy-King College’s Dental Hygiene
Department
Dr. Robert Laveau at UIC Podiatry Clinic
Jonikas, Glover, & Cook, 2014
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Jonikas, Glover, & Cook, 2014
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Key Study Partners
Sue Braun
Emily Brigell
Kathy Christiansen
Kristin Davis
Katy Dobbins
Jay Forman
Jonikas, Glover, & Cook, 2014
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Ann Heesacker
Asma Jami
Sheila O’Neill
Deborah Pavick
Pam Steigman
Joni Weidenaar
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A Public Health Crisis
People in recovery have
a higher prevalence of
diabetes:
• Lifestyle factors
• Psychiatric medications
that cause blood sugar
disorders
• Complicated illness
- doctors & patients often
unsure of what’s behind
poorly controlled glucose
People with diabetes are
at-risk for developing:
Hypertension
Hyperlipidemia
Heart disease
Kidney disease
Gum disease/loss of teeth
Nerve damage/loss of feet
Eye disease/becoming
blind
• Costs are 2.4 times greater;
nearly 40% of costs due to
long-term complications.
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Jonikas, Glover, & Cook, 2014
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Use of a Registry to Manage Care for Diabetes in Integrated
Health Clinics for Adults with Serious Mental Illnesses
Judith A. Cook, PhD, Principal Investigator
Introduce a diabetes registry to:
1. Improve care delivery
 full adherence to ADA standards of care
 develop new treatment & service resources
2. Enrich care coordination
 link clients to needed specialty care in accordance
with ADA standards
 teach clients about diabetes and its complications
3. Better monitor health indicators and outcomes over time
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Free Diabetes Toolkit
http://www.cmhsrp.uic.edu/health
/diabetes-library-home.asp
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/
What is a Diabetes Registry?
 Database with demographics,
illness characteristics, treatment
delivered, and specialty care
arranged/delivered
 Information from electronic and
paper records guides care,
tracks outcomes, and informs
plans for improving care
 Supports proactive care by
facilitating care planning,
sharing of information with
other providers, and generating
patient reminders
 Generates charts and graphs
to support illness selfmanagement
 Generates reports to monitor
team and system
performance
 Overall goal is to improve
adherence to treatment
guidelines and selfmanagement
Jonikas, Glover, & Cook, 2014
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Sample Standards Tracked in Diabetes Registries
for Individual & Population Management
Standard
Target
Blood Glucose Control (HbA1c)
Less than 7%
Blood Pressure
Less Than 140/90 mmHg
LDL cholesterol
Less Than 100 mg/dl
Urine Screening for Microalbumin
Annual screening
Dilated eye exam
Annual screening
Foot exam for neuropathy
Annual screening
Dental exam
Annual screening
Vaccinations
Lifetime and annual
Jonikas, Glover, & Cook, 2014
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Jonikas, Glover, & Cook, 2014
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How are data entered?
Different options depending on resources:
1. Clinicians enter data manually themselves during
or after visits
2. Clinicians complete diabetes encounter forms,
which are sent to a central site for data entry that
is supported by a registry project
3. Care coordinators obtain information for the
registry from patient records after each visit
4. Clinicians complete diabetes encounter forms,
which are given to the Care Coordinator to enter
into the registry
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
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Why Registries for Standards of Care?
 One electronic database
contains data from multiple
sources to inform complex
disease processes
 Quickly focuses effort on
better managing chronic
disease at population level
 Can be used by multiple
parties (clinicians, patients,
administrators) to facilitate
care delivery while meeting
care standards
(Ortiz, 2006)
Jonikas, Glover, & Cook, 2014
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Registries and Patient-Centered Care
 Allows clients to see their test
results related to 1 or more
conditions all in one place
 Permits clients to share
current results with specialists
and other providers for
safer/better care
coordination and outcomes
 Helps clients track their
own results over time,
assess personal
improvements, and
identify areas of concern
 Enables clients to
compare their test results
and health outcomes
with those of peers or the
general population
Jonikas, Glover, & Cook, 2014
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Why Registries for Care Coordination?
 Allows for identification
and monitoring of clients
with a specific need within
a clinic or across clinics
 Fosters individual disease
management through
notifications of abnormal
test results, missed
appointments, and up-todate information on client
encounters
 Promotes use of evidence-
based and values-driven
care
 Puts the focus on the needs
and progress of high-risk
clients to manage limited
resources (client & clinic)
 Facilitates health outcomes
management at both the
individual and clinic levels
(Hummel, 2000)
Jonikas, Glover, & Cook, 2014
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Population Studies using a Diabetes Registry
Improving Diabetes Care in a Large Health Care System:
An Enhanced Primary Care Approach
Sperl-Hillen, et al. (2000). Joint Commission Journal on Quality and
Patient Safety
Improved glycemic and lipid control among approximately 7,000
adults with diabetes.
The Impact of Planned Care and a Diabetes Electronic
Management System on Community-Based Diabetes Care:
The Mayo Health System Diabetes Translation Project
Montori et al. (2002). Diabetes Care.
Registry use augmented the impact of planned care on
performance outcomes (increased use of specialty medical care)
and certain metabolic outcomes. Did not impact glucose levels.
Jonikas, Glover, & Cook, 2014
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Jonikas, Glover, & Cook, 2014
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Diabetes Registries: Across Clinics
Improving Diabetes Outcomes Using a Web-Based
Registry and Interactive Education: A Multisite
Collaborative Approach
Morrow, R. et al., (2013). Journal of Continuing Education in the Health
Professions
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Electronic diabetes registry in 7 clinics in NY
With educational module on the registry and patient communication
With each quarter post-Registry, patients were:
• 1.4 times more likely to have A1C ≤ 9
• Almost twice as likely to have LDL < 100
• 1.3 times more likely to have BP < 140/90
Likelihood of adherence increased over the initial quarters (except for BP;
adherence dipped over time). There was a drop-off among all indicators after
5 quarters, suggesting ongoing support and training are needed
Jonikas, Glover, & Cook, 2014
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Jonikas, Glover, & Cook, 2014
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Okay, but why not just use an Electronic Health Record?
 Most EHRs are not built to function as registries, so
can’t support population-based care
 It can take years for population reporting from an
EHR
 A registry is relatively easy and inexpensive
• Can have nearly immediate impact on clinic practice and
client engagement & outcomes
 It can be instructive to learn population-based care
parameters prior to implementing an EHR via a
registry
• Allows you to design EHR processes to support needs
identified by registry use
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Content adapted from:
www.powershow.com/view/21d14Jonikas, Glover, & Cook, 2014
MzEyZ/Using_Excel_for_a_HgA1c_Registry_powerpoint_ppt_presentation
www.cmhsrp.uic.edu/health/
Platform Options
CDEMS
cdems.com
 Relational database
 Challenging to learn and
implement
 Technical support no longer
available
Doc Site
portal.covisint.com/web/supporthc
/ccahc
• Web-based; easy to access
• Can role up nationally
• Annual per provider fee
CareMeasures
www.caremeasures.org/CareMeasur
es/public/Default.aspx
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Easy to use & customize
Manages multiple conditions
Must register & pay fees
Excel
http://www.aafp.org/fpm/2006/0400/
p47.html
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Free software and template
Easy to learn and implement
- Storing only the most
recent results
Good for population
management of single
disease
Content adapted from:
Jonikas, Glover, & Cook, 2014
www.powershow.com/view/21d14MzEyZ/Using_Excel_for_a_HgA1c_Registry_powerpoin
www.cmhsrp.uic.edu/health/
t_ppt_presentation
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/
www.aafp.org/fpm/2006/0400/p47.html
Population Management via Reports
Client Last Name
Client
Birthdate
Ryan
Value of most
recent A1C
Date of most recent A1C
03/31/40
9.8
09/05/2014
Bell
05/25/72
8.9
02/18/2013
Cruz
06/16/60
7.8
06/17/2013
Smith
01/15/65
7.1
08/15/2014
Ramirez
05/24/61
6.5
08/01/2013
Jordan
09/12/60
6.5
09/12/2013
Stock
10/10/80
6.2
07/13/2014
Blake
12/12/40
5.2
05/14/2014
Bergman
11/12/61
5.0
05/05/2014
Jonikas, Glover, & Cook, 2014
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Provider
Sort by test
value to
determine
who is
most at
risk
Registry Reports from a
Simple
Jonikas, Glover, & Cook, 2014
Microsoft Excel-based Registry
www.cmhsrp.uic.edu/health/
Care Coordination via Reports
Client Last Name
Client Birthdate
Bell
05/25/72
11/11/2011
Cruz
06/16/60
06/10/2012
Ramirez
05/24/61
04/15/2013
Jordan
09/12/60
02/17/2013
Smith
01/15/65
10/16/2013
Ryan
03/31/40
10/17/2013
Stock
10/10/80
04/13/2014
Bergman
11/12/61
03/05/2014
Blake
12/12/40
02/14/2014
Jonikas, Glover, & Cook, 2014
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Provider
Date of most recent eye exam
Sort by test
date to
determine
who is
overdue and
needs care
coordination
Registry Reports from a
Simple
Jonikas, Glover, & Cook, 2014
Microsoft Excel-based Registry
www.cmhsrp.uic.edu/health/
Performance Management via Reports
Client Last Name
Client
Birthdate
Provider
Value of most recent
A1C
Date of most recent A1C
Ryan
03/31/40
Dr. S
9.8
09/05/2013
Smith
01/15/65
Dr. S
7.1
08/15/2014
Ramirez
05/24/61
Dr. S
6.5
08/14/2014
Jordan
09/12/60
Dr. S
6.5
08/17/2014
Bell
05/25/72
Dr. A
8.9
02/18/2014
Cruz
06/16/60
Dr. A
7.8
06/17/2013
Stock
10/10/80
Dr. A
6.2
08/17/2014
Blake
12/12/40
Dr. A
5.2
09/14/2014
Bergman
11/12/61
Dr. A
5.0
09/05/2014
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Sort by
provider then
value to
identify
performance
goals
Registry Reports from a
Simple
Jonikas, Glover, & Cook, 2014
Microsoft Excel-based Registry
www.cmhsrp.uic.edu/health/
The Purpose of Our Registry
Introduced to:
→ Fully adhere to ADA standards of care by
improving care delivery and coordination
→ Link participants to specialty care in accordance
with ADA standards
→ Teach participants about diabetes and its
complications
→ Develop new treatment/service resources
→ Monitor health indicators and outcomes over time
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/
The Collaboration
 UIC College of Nursing staff operate the nurse-managed Integrated
Health Clinics (IHCs) where study participants received medical care.
At the time the initial study sample was drawn, the IHCs were serving
220 patients with co-occurring diabetes & mental illness.
 Thresholds houses one IHC on Chicago’s north-side and one on
Chicago’s south-side. Thresholds provided community support and
linkage to Registry clients to help them attend the IHCs and specialty
appointments, and to self-manage their co-occurring conditions.
 UIC Center on Psychiatric Disability and Co-Occurring Medical
Conditions staff built the registry which was populated with data on
the 220 patients; the UIC Center funded the study’s Care Coordinator
who liaisoned with IHC and Thresholds staff, focusing specifically on
increasing adherence to diabetes care standards.
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
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A Tour of our Registry
o
Chronic Disease Electronic Management System (CDEMS)
platform
o
A relational database with demographic information, illness
characteristics, treatment delivered, and specialty care
arranged and delivered
o
Baseline data derived from 2011 IHC visits, with updates made
each time a patient received treatment, including nurse visits,
laboratory work, patient education, and/or specialty care
o
Generated patient- and clinic-level reports
o
Reports allowed for tracking of clinic-wide adherence to American
Diabetes Association standards of care, as well as monitoring
patients’ diabetes-related needs and outcomes
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
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Registry & Coordination Procedures to Impact on Outcomes
 Patient-specific reports from
the registry were provided to
nurses prior to each patient
visit
 helped orient them to the
most recent treatment(s),
upcoming tests or
appointments, and the
most pressing concerns
 Patient education was
chosen from comprehensive
materials to address each
patient’s specific needs and
strengths at each visit
 Patient education materials
were also shared with
community support workers
to reinforce this learning in
the community
 Specialty care needs were
identified for each patient
 Support given for each
client to see specialists, in
accordance with the ADA
standards of care
(including optometrist,
dentist, and podiatrist)
Jonikas, Glover, & Cook, 2014
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Sample Patient Specific Registry Report
Jonikas, Glover, & Cook, 2014
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Jonikas, Glover, & Cook, 2014
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Sample Patient Report Designed for Education &
Self-Management
Jonikas, Glover, & Cook, 2014
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Jonikas, Glover, & Cook, 2014
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Sample
Patient
Education
Jonikas, Glover, & Cook, 2014
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Registry Study Sample (n = 217)
• 67% male
• 2/3 members of racial/ethnic groups:
– 60% African American; 27% White;
4% Hispanic/Latino; 2% Asian; 7% Other
• Age range: 20 to 77 years (mean=51; sd.=10)
• 54% were patients at the north-side clinic
• 46% were patients at the south-side clinic
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
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Preliminary Medical Outcomes
Changes in glucose management following introduction of the Registry
and Care Coordination:
 The least controlled (i.e., poorest) A1c level during the pre-test years of
2010-2012 (N=205) averaged 7.97 per patient
 A1c at the most recent visit during the post-test years of 2013-2014
(N=201) averaged 6.93 per patient
 In other words, there was significant improvement from poorest to most
recent A1c, decreasing by 1 point on average (t=5.08, p<.001).
 Every 1% improvement in A1c is associated with a 25% decrease in a
combined index of cardiovascular complications for people with type
2 diabetes (UK Prospective Diabetes Study Group, 1998).
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
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Preliminary Medical Outcomes
Changes in total cholesterol and triglycerides following introduction of
the Registry and Care Coordination:
 Worst total cholesterol (TC) during the pre-test years (N=197)
averaged 180 mg/dL per patient, while the average at post-test was
165 mg/dL (N=170) (t=3.5, p<.001)
 Worst triglycerides level in pre-test years averaged 165 mg/dL per
patient (n=198), while the average at post-test was 143 mg/dL
(N=169) (t=2.2, p<.05)
 The average TC and triglycerides showed significant improvement,
with lipids and triglycerides dropping by 27 or more points.
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
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Preliminary Specialty Care Outcomes
Changes in adherence to the ADA standards of care following
introduction of the Registry and Care Coordination:
 Between 2010-2012, completed dental referrals had a percentage
increase of 500%
 2.8% at pre-test, 16.6% at post-test (χ2 = 23.74, p < 0.001)
 Between 2010-2012, completed optometry referrals had a percentage
increase of 65%
 21% at pre-test, 35% at post-test (χ2 = 10.1, p < 0.01)
 Between 2010-2012, completed podiatry referrals had a percentage
increase of 88%
 15% at pre-test, 28% at post-test (χ2 = 11.3, p < 0.01)
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
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Key Barriers to Registry Use
 Shifting from
reaction to
prevention
 Moving from
individual level to
population-based
care
 Getting multiple
partners invested
 Time to load and
maintain the
spreadsheet or
database
 Measuring
performance can
be threatening
 Just another fad?
Content adapted from:
www.powershow.com/view/21d14MzEyZ/Using_Excel_for_a_HgA1c_Registry_powerpoint_ppt_presentation
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/
Reflections and Next Steps
 Registries, especially those in a simple Excel format, can quickly
focus attention on the needs of those clients who most require
integrated and coordinated care efforts
 The role of the behavioral health case manager/support worker is
expanding to require expertise in medical management and
medical care coordination
 Integrated patient education, health literacy, and selfmanagement are critical promotion and prevention approaches
 Front-line and supervisory staff also benefit from employee health
and wellness programs
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/index.asp
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/
Learn about our registry
study
www.cmhsrp.uic.edu/health/medical_home_re
gistry.asp
Free Diabetes Toolkit
http://www.cmhsrp.uic.edu/health/diab
etes-library-home.asp
Jonikas, Glover, & Cook, 2014
www.cmhsrp.uic.edu/health/